Introduction - What is Lymphedema (Lymphoedema)?Lymphedema is an abnormal collection of high-protein fluid just beneath the skin. This swelling, or edema, occurs most commonly in the arm or leg, but it also may occur in other parts of the body including the breast or trunk, head and neck, or genitals. Lymphedema usually develops when lymph vessels are damaged or lymph nodes are removed (secondary lymphedema) but can also be present when lymphatic vessels are missing or impaired due to a hereditary condition (primary lymphedema).
Lymphatic fluid is normally transported out of a region of the body by an extensive network of lymph vessels. When the collection of protein-rich fluid persists in a specific area, it can attract more fluid and thus worsen the swelling. In addition to increased fluid in the area, the body experiences an inflammatory reaction resulting in scar tissue called fibrosis in the affected area. The presence of fibrosis makes it even more difficult for the excess fluid to be eliminated from the area. As a result, the increased fluid and fibrosis prevents the delivery of oxygen and essential nutrients to the area, which in turn can delay wound healing, provide a culture medium for bacteria to grow, and increase the risk of infections in or below the skin called cellulitis or lymphangitis.
Lymphedema should not be confused with other types of edema resulting from venous insufficiency (leaky or obstructed veins), cardiac conditions like heart failure or sleep apnea, kidney failure, or other inflammatory processes. These conditions are not lymphedema and are generally treated differently.
Types & Causes of LymphedemaLymphedema can be described as primary or secondary:
Common Causes of Secondary Lymphedema
|Surgery - particularly when lymph nodes are removed after treatment for cancer: breast, prostate, gynaecological, head or neck, sarcoma or melanoma.|
|Radiotherapy - this kills cancer/tumour cells, but it can also cause scar tissue that interrupts the normal flow of lymph in the lymphatic system.|
|Accidental trauma/injury or infection that may damage the lymph vessels and cause reduced drainage of lymph fluid.|
|Reduced mobility/paralysis - muscle contractions (during activity/exercise) are important to help the lymph to move.|
|Problems with veins not working very well (varicose veins/after deep vein thrombosis) - often known as venous insufficiency. This results in the lymph system becoming overloaded and unable to function effectively.|
|Cancer itself may also result in a blockage of the lymphatic system.|
However, if patients know they are "at risk" for developing lymphedema (usually because they are having lymph nodes removed or radiation therapy as part of cancer treatment), with early referral (i.e. 2 weeks post-surgery or during radiation therapy or their lymphedema is in stage 0 or stage 1) therapists at our sister clinic, Oncology Rehab have treatment protocols to facilitate the healing of the lymphatic system and mitigate the risk of developing the condition.
The Stages & Symptoms of LymphedemaLymphedema usually progresses through a series of stages so it is really important to get help right away, even if your initial symptoms don’t seem too worrying or they come and go. One episode of numbness, tingling, or swelling just about always will lead to more. Try an act when you have early symptoms or the continued buildup of lymph can cause permanent damage to the tissues under the skin. According to the International Society of Lymphology, the stages are:
- Stage 0 (also called subclinical or latent): There are no visible changes to the arm, leg, hand, or upper body at this point, but you may notice a difference in feeling, such as a mild tingling, unusual tiredness, or slight heaviness. You can have stage 0 lymphedema for months or years before obvious symptoms develop - At this stage, Oncology Rehab (if the lymphedema is a result of cancer treatment), can treat the lymphatic system to help it heal and mitigate the condition developing further.
- Stage 1 (mild): The arm, leg, hand, trunk, breast, or other area appears mildly swollen as the protein-rich fluid starts to accumulate. When you press the skin, a temporary small dent (or pit) forms; you may see this referred to as “pitting edema.” Such early-stage lymphedema is considered reversible with treatment because the skin and tissues haven’t been permanently damaged. Again, arrange an appointment with Oncology Rehab (if the lymphedema is a result of cancer treatment) - their therapists can treat the lymphatic system to help it heal and mitigate the condition developing further.
- Stage 2 (moderate): The affected area is even more swollen. Elevating the arm or other area doesn’t help, and pressing on the skin does not leave a pit (non-pitting edema). Some changes to the tissue under the skin are happening, such as inflammation, hardening, or thickening. Stage 2 lymphedema can be managed with treatment, but any tissue damage can’t be reversed. Edema Rehab and Oncology Rehab are experts at managing Stage 2 lymphedema
- Stage 3 (severe): This is the most advanced stage. At stage 3, the affected limb or area of the body becomes very large and misshapen, and the skin takes on a leathery, wrinkled appearance. Again, we are very experienced in helping you manage your condition - we can help you.
Early signs and symptoms of lymphedema can be intermittent and may include:
- transient swelling of a limb or other region of the body
- infection (due to lymph stasis) is often the first sign of a problem
- feelings of aching, heaviness, stiffness in the affected body part
- limitation of movement
- tightness or temperature changes to areas of the body
- clothing, jewellery or shoes may feel tighter
- swelling may be aggravated by heat, overuse, sustained positions and prolonged inactivity and be more obvious at the end of the day
The Lymphatic SystemThe lymphatics form part of your immune system, helping to deal with infection at a local level but just as importantly, they are responsible for cleansing your tissues and maintaining a balance of fluids in your body. It can be likened to a waste disposal system, taking tissue fluid, bacteria, proteins and waste products away from the tissues around skin, fat, muscle and bone.
Once inside the lymphatic vessels (which initially are barely visible just under the surface of the skin) the tissue fluid becomes known as 'lymph' and it is then transported in one direction by increasingly larger and deeper lymphatic vessels. Movement of lymph depends on muscle movement (exercise) and the contraction of the vessels themselves. Gentle massage known as Manual Lymph Drainage (MLD) and deep breathing can also help to move the lymph more effectively.
At some point in its journey, lymph will pass through a lymph node, or gland. Clusters of these nodes are found in the neck, armpits and groins. It is here that the lymph is filtered and cleansed, so that the waste matter and harmful cells can be identified and removed by the body's defense system.
Having passed through these nodes, lymph finally drains back into the large veins of the body at a point just behind the collarbone, on each side of the neck. From here it goes back to the heart and is eventually removed from the body as urine through the kidneys.
If you want to understand more about how the lymphatic system works, there is an excellent poster on the Lymph Drainage System here.